facial analysis. a chomprensyve approach to treatment planning in ahesthetic dentistry.pdf

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The primary objective of aesthetic dental treatment is

to generate a natural, healthy appearance for an

otherwise damaged dentition. In order to fulfill this com-

plex task, an interdisciplinary approach is required tosynchronize periodontal, orthodontic, restorative, and

occasionally plastic surgical treatment modalities, which

results in a comprehensive treatment plan. A detailed

diagnosis of the given facial architecture and dental con-

figuration with analysis of the individual patient aesthet-

ics are required to initiate the treatment plan.

Historically, attempts to define the essence of

beauty were a combination of artistic expression and

mathematical proportions. Aesthetics is an element of

philosophy, concerning the science of beauty, and is often

associated with circumscriptions such as “good” and

“true.” Numerous diagnostic techniques are presently

used to assist this study and transform the components

of a less-than-optimum face into more attractive forms.

While dental clinicians utilize full-mouth radiographs and

diagnostic models to evaluate the condition of their

patients’ teeth, analysis of the anterior and lateral facialskeletal relationships and their soft tissue drape is often

overlooked in these examinations.

An incomplete diagnosis may occur when one

neglects to review cephalometric linear and angular mea-

surements, the facial contours, and the position of the nose,

lips, and chin. Since the alteration of cheek support, nasal

base and lip support, chin projection, and length of the

throat can have dramatic effects on the final outcome,

a subtle modification in any of the aforementioned struc-

tures will change the harmony of the whole. Although

F ACIAL A NALYSIS: A COMPREHENSIVE

A PPROACH TO TREATMENT PLANNING

IN A ESTHETIC DENTISTRY Robert Rifkin, DDS*

Pract Periodont Aesthet Dent 2000;12(9):865-871

Figure 1. Postural head position (PHP) with relaxed mouthopening displaying facial midline, interpupillary line (IPL),and commissural/incisal line.

*Private practice, Beverly Hills, California.

Robert Rifkin, DDS 414 N. Camden Drive Suite 1280 Beverly Hills, CA 90210

Tel: (310) 205-0010 Fax: (310) 205-0718 E-mail: [email protected]

Patient aesthetic expectations and smile enhancement can

be achieved through the use of facial analysis. This

process allows each member of the restorative team (ie,

clinician, specialist, dental technician) to diagnose the

patient and develop a comprehensive treatment plan for

his or her specific needs. Treatment planning according

to facial architecture and dental configuration allows

function and harmonious aesthetics to be improved. This

article demonstrates a predictable means to evaluate

the components of an attractive face for use as a guide

during aesthetic dental treatment.

Key Words: aesthetics, plane, line, cephalometric

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diversity exists with regard to ethnicity and variations in

preference, which ultimately influence the definition of

aesthetics,1 an appearance that is generally considered

“aesthetic” can be related to principles of specific

symmetries and relationships.2-12

The purpose of this article is to present a multifacto-

rial analysis of a patient’s functional and aesthetic defi-

ciencies and its transformation into a comprehensive

treatment plan. The definitive goal of a preconceived treat-

ment plan is to achieve individually enhanced aesthetics

and subsequently increase patient satisfaction.

DiagnosisSoft Tissue — Frontal View

The natural postural head position,13 which allows the

patient to sit or stand upright in front of the observer, is

the optimal position for an evaluation of the frontal plane.

The interpupillary line, facial midline, and commissural

line with the lips slightly open are important landmarks

for the evaluation of smile harmony (Figure 1).14 Facial

disproportion can be easily ascertained during exami-

nation of the frontal plane through the examination of

any existing disharmony in the interpupillary line, incisal

line, and the facial midline. By observing the exposed

teeth during a natural smile and wide smile, the clinician

can evaluate a high, medium, or low commissural line,

as well as an irregular arch.

The symmetry of the face and dental midline

is defined by the facial midline. The orientation of the

anticipated dental midline can be influenced by the

observation of the dorsum of the nose and its curvature

as well as Cupid’s Bow and the papilla between the

central incisors. The interpupillary line is a reference plane

used to determine the incisal plane, the gingival plane,

and the occlusal plane.

Figure 3. Postural head position with display of facialthirds in an ideal patient. This is useful for evaluating

midface and lower face height (eg, open and closed bite[posterior bite collapse] cases).

Figure 4. Postural head position for evaluation of theprofile using the angle glabella-subnasale-soft tissuepogonion. This permits analysis of eye-cheek relation-ships, lip position, and lip competence/incompetence.

Figure 2. Characteristic facial landmarks: curvature of thedorsum, angulation of the base of the nose, and ratio of

upper lip length to lower lip length in PHP.

866 Vol. 12, No. 9

Practical Periodontics & AESTHETIC DENTISTRY

18 mm to 20 mm 1X

36 mm to 40 mm 2X

Upper 1/3

Middle 1/3

Lower 1/3

Glabella

Subnasale

Pogonion

165° to 175°



In optimum facial aesthetics, the distance from sub-

nasale (base of the nose) to the upper lip should be approx-

imately half the length of the lower lip to menton (lowest

chin point) (Figure 2). When treatment is performed on

advanced cases, an evaluation of the facial thirds — from

the hairline to midbrow, midbrow to subnasale, and sub-

nasale to soft tissue menton — is required in order to

obtain a more ideal facial proportion (Figure 3).10,15

Soft Tissue — Lateral View

When the patient is observed from a lateral perspec-

tive, the natural postural head position10,13,16,17 is favored

over the Frankfort horizontal plane, which exhibits greater

variation. This allows the patient’s natural appearance

to be displayed for optimum clinical evaluation. The

patient’s profile angle extends through the glabella, sub-

nasale, and soft tissue pogonion, and should be approxi-

mately 165° to 175° for Class I occlusion (Figure 4).14

The nasolabial angle is constructed from two lines (one

tangent to the base of the nose and one to the upper

vermillion border of the lip) that intersect at subnasale;

the measurement of this angle generally ranges from

85° to 105° (Figure 5).

Aesthetic lip positions can be determined through

the use of numerous measurements. Ricketts’ E-plane,which describes a line that extends from the tip of the

nose to the chin, is one principal reference (Figure 6).

In this plane, the maxillary and mandibular lip positions

measure –4 mm and –2 mm, respectively. A second alter-

native is the Steiner line, in which the midpoint of the

nose is connected to the chin, and the patient’s lips touch

this line. The Burstone line, which connects the subnasale

point to the pogonion point, can also be used for diag-

nosis. The maxillary and mandibular lip are compressed

by this reference line (ideally +3.5 mm and +2.2 mm,respectively, ahead of this line).17-20 By analyzing the

patient’s medium and maximum smile in comparison to

Figure 6. Lip position according to Ricketts, Steiner, andBurstone reference lines.

Figure 5. In PHP, the nasiolabial angle (NLA) shouldrange from approximately 85° to 105°.

Figure 7. An example of cephalometric reference planessuperimposed over soft tissue profile.

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NLA

85° to 105°

Steiner

Ricketts

Burstone



its relaxed position, the clinician can determine any

necessary variation for the definitive restorative result.

In patients who exhibit significant aesthetic compro-

mise, throat length — the distance from the neck-throat

junction to the soft tissue menton — and contour should

be evaluated. If asymmetry exists, orthognathic surgery, Le

Fort I maxillary osteotomy, or bilateral sagittal split

mandibular osteotomy of the mandible with setback or

advancement must be considered.20 When skeletal defor-

mities contribute to facial disharmony, the necessity of

cheekbone contouring (ie, maxillary Le Fort procedure)

should also be addressed.21 Since aesthetic restorations

can modify the patient’s smile, a thorough explanation

of the definitive result should be provided for the patient

prior to treatment. The use of computer imaging software

can be an effective means of communicating the antic-ipated aesthetic result to the patient. The author, how-

ever, prefers the use of flowable composite resins or

provisional acrylic veneer templates over the patient’s

dentition. As with the imaging systems, these methods

allow the patient to observe potential enhancement, but

the use of resin and veneers also permits phonetic and

proprioceptive evaluation. The final guidelines for the

definitive restorations are the second set of provisional

restorations as completed by the “sandwich technique.”12

Cephalometry

The anteroposterior and vertical configuration of the facial

skeleton can be analyzed with cephalometric radiographs.

Cephalometrics also allow the verification of the soft tissue

morphology in a profile view without necessitating the

removal of the overlaying soft tissue (Figure 7). With the

utilization of cephalometrics, the relationship of the axial

inclination of incisors and the localization of malocclusions

can be assessed to determine Class II, Class III, open bite,

or deep bite situations. By establishing reference points

in the region of the craniofacial skeleton, reference lines

and planes can be constructed and subsequently mea-

sured linearly or angularly to determine disparities.18,19

Due to the variability of intracranial reference lines and

planes (eg, Frankfort Horizontal, Sella-Nasion), these guides

can only serve as adjuncts to the natural head position

and the true horizontal plane in treatment planning.13,16,17

Figure 8. Preoperative facial view of the patient. Relationof upper to lower lip length is less than the normal 1:2ratio. Deep mandibular concavity of lower lip due to deepoverbite and resultant decreased vertical dimension.

Figure 9. Preoperative lateral view of the patient in centricrelation demonstrating compressed upper lip and deeplower lip concavity due to posterior bite collapse. Noteabnormal nasolabial angle.

Figure 10. Preoperative view of existing restorations.Note deep overbite and axial inclination.

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Dental Analysis

Numerous variables (eg, embrasures, axes, zeniths,

shapes) contribute to the appearance of the dentition

and consequently the appearance of the patient. While

these factors are certainly associated with facial aes-

thetics and have been the focus of myriad clinical reports,

they remain beyond the scope of this article.

Case Presentation

A 27-year-old female patient presented for the replace-

ment of existing laboratory-fabricated resin full-coverage

crowns on teeth #6(13) through #11(23) (Figures 8

through 10), which had fractured during function. The

patient reported discomfort in the condylar region and

was unable to move her mandible without crossarch

interferences. Clinical examination and facial analysisrevealed the presence of a deep overbite, posterior bite

collapse, and a lack of proper foundation restorations

beneath the fractured crowns. Lack of proper lingual

concavity was also evident for the maxillary anterior

dentition; the patient’s mandibular teeth extended into

the opposing cingulum and palatal tissue (Figure 11).

Upon radiographic examination, root resorption from

prior orthodontic treatment was noted on teeth #6

through #11. Analysis of the temporomandibular joint

and occlusion indicated the patient’s inability to performprotrusive or lateral movements without difficulty.

Upon consultation with the laboratory technician

and the patient, a comprehensive interdisciplinary treat-

ment plan was developed. Adjunctive orthodontic ther-

apy would be initiated for a period of 8 months and

involve a repositioning splint. The posterior dentition

would then be extruded to restore the proper vertical

dimension, and endodontic treatment would be neces-

sary prior to final rehabilitation of teeth #6 through #11.

The patient consented to the proposed therapy, and

treatment was initiated.

Clinical Phase

Alginate impressions were made for study models prior

to treatment. The shade of the anticipated restorations

was subsequently recorded following one month of at-

home bleaching, and the maxillary teeth were prepared

Figure 12. View of initial (first set) provisional restora-tions used for evaluation of aesthetics, phonetics, andfunction at new vertical opening. Compare to figure 10.

Figure 11. The existing restorations are removed; patient is at proposed vertical dimension. This new position willrestore lost vertical dimension and lingual concavity ofmaxillary anterior teeth.

Figure 13. Acrylic resin provisional restorations wereseated on the posterior dentition to establish a new vertical opening for the patient.

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and provisionalized at the proposed new vertical posi-

tion with acrylic resin restorations that were placed over

cast-gold posts and cores (Figures 12 and 13). In order

to harmonize with the ideal facial drape determined by

the preoperative facial analysis, the vertical dimension

was opened 4 mm; this would also reduce the exces-

sive maxillary anterior angulation and deep overbite.

This was accomplished once the seating of the condyles

was confirmed; the resulting open posterior space then

required extrusion of both maxillary and mandibular seg-

ments. Orthodontic therapy was performed, and the final

restorative phase was instituted.

The initial set of provisional restorations were evalu-

ated for phonetics, aesthetics, and function while a sec-

ond set of acrylic provisional restorations were fabricated

with various refinements and characterizations accord-ing to the sandwich technique (Figures 14 through 16).

The template used to construct the final (second) acrylic

provisional restorations was also obtained from alginate

impressions of the first set of acrylic restorations; the final

impressions of the preparations used to fabricate the

definitive metal-ceramic restorations were recorded in

polyvinylsiloxane (Take 1, Kerr/Sybron, Orange, CA).

The definitive posterior full-coverage crown restorations

were seated with a resin ionomer cement, and the

endodontically treated anterior teeth were restored with

porcelain-fused-to-metal crowns (Figure 17). The finalrestorations satisfied the expectations of the patient, her

family, and the restorative team (Figures 18 and 19).

All members of the restorative team were integral to the

success of the definitive aesthetic design.

Conclusion

As this article demonstrates, the determination of the

proper proportions to achieve an individual’s desired

facial aesthetics requires a comprehensive facial analy-

sis. In patients that present for complex rehabilitation, it

may be advisable to utilize cephalometric radiographs

to determine existing disparities. Beyond the soft tissue

analysis, a thorough dental analysis should be performed

to ascertain dentition deformities that contribute to the

facial disharmony. As with all procedures, effective com-

munication between all involved teams is required to

arrive at a satisfactory treatment plan.

Figure 14. In the laboratory, a detailed waxup of the anticipatedfinal restorations is used to fabricate the second set of acrylicprovisional restorations.

Figure 15. A second set of acrylic resin provisional restorations isfabricated according to the “sandwich technique.” Note light-curedresin characterization and tinting.

Figure 16. Facial view of the second set of acrylic resin full-coveragecrown restorations upon completion.

870 Vol. 12, No. 9




Acknowledgment

The author mentions his gratitude to Stefan Paul, DMD,

PhD, William Arnett, DDS, and Emanuel Wasserman,

DDS, MSD, for their assistance, and Michel Magne, MDT,

for the fabrication of some of the restorations presented

herein. The author has no financial interest in any of the

products cited in this presentation.

References1. Johnson PF. Racial norms: Esthetic and prosthodontic implica-

tions. J Prosthet Dent 1992;67(4):502-508.

2. Farkas LG, Hreczko TA, Kolar JC, Munro IR. Vertical and hori-zontal proportions of the face in young adult North Americancaucasians: Revision of neoclassical canons. Plast Reconstr Surg1985;75(3):328-338.

3. Peck S, Peck L. Selected aspects of the art and science of facialesthetics. Semin Orthod 1995;1(2):105-126.

4. Nanda RS, Ghosh J. Facial soft tissue harmony and growth inorthodontic treatment. Semin Orthod 1995;1(2):67-81.

5. Ahmad I. Geometric considerations in anterior dental aesthet-ics: Restorative principles. Pract Periodont Aesthet Dent 1998;10(7):813-822.

6. Spear F. Facial generated treatment planning: A restorative view-point. American Academy of Esthetic Dentistry, 16th AnnualMeeting. Santa Barbara, CA; 1991.

7. Kerns LL, Silveira AM, Kerns DG, Regennitter FJ. Esthetic pref-erence of the frontal and profile views of the same smile. J EsthetDent 1997;9(2):76-85.

8. Belser U. Esthetic checklist for fixed prosthodontics. In: SchärerP, Rinn LA, Kopp ER. Esthetic Guidelines for Restorative Dentistry.Carol Stream, IL: Quintessence Publishing, 1982.

9. Bichacho N, Magne M. Controlled restorative treatment of com-promised anterior dentition. Pract Periodont Aesthet Dent1998;10(6):723-727.

10. Rakosi T, Jonas I, Graber TM. Orthodontic diagnosis. In: Rateitschak KH, Wolf HF, eds. Color Atlas of Dental Medicine. OrthodonticDiagnosis. Stuttgart, Germany: Thieme; 1993:108-115.

11. Touati B, Miara P, Nathanson D. Esthetic Dentistry and CeramicRestorations. London, UK: Martin Dunitz, Ltd.;1999:117-138.

12. Magne P, Magne M, Belser U. The diagnostic template: Akey element to the comprehensive esthetic treatment concept.Int J Periodont Rest Dent 1996;16(6):560-569.

13. Viazis AD. A cephalometric analysis based on natural head posi-tion. J Clin Orthod 1991;25(3):172-181.

14. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosisand treatment planning. Part I. Am J Orthod Dentofacial Orthop1993;103(4):299-312.

15. Rufenacht CR. Fundamentals of Esthetics. Carol Stream, IL: Quin-tessence Publishing, 1990.

16. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosisand treatment planning. Part II. Am J Orthod Dentofacial Orthop1993;103(5):395-411.

17. Viazis AD. A new measurement of profile esthetics. J Clin Orthod1991;25(1):15-20.

18. Viazis AD. Atlas of Advanced Orthodontics. A Guide to ClinicalEfficiency. Philadelphia, PA: WB Saunders; 1998:41-43.

19. Burstone CJ. Lip posture and its significance in treatment plan-ning. Am J Orthod 1967;53:262-284.

20. Weickersheimer PB. Steiner analysis. In: Jacobson A, ed.Radiographic Cephalometry. Carol Stream, IL: QuintessencePublishing; 1995:83-85.

21. Bell WH. Modern Practice in Orthognathic and ReconstructiveSurgery. Philadelphia, PA: W.B. Saunders, 1992.

Figure 18. Postoperative lateral view of restored vertical dimension.Note axial inclination of anterior dentition as compared to figure 10.

Figure 17. The posterior dentition were ultimately restored withfull-coverage metal-ceramic crown restorations (Omega 900, Vident, Brea, CA ).

Figure 19. Lateral view of soft tissue drape posttreatment. Noteimproved nasolabial angle, lip aesthetics, and concavity.

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1. Treatment planning and facial analysis willallow improvements:a. With respect to function.b. With respect to a proportional and harmonious

smile.c. With the natural and aesthetic appearance

of the final restoration.d. All of the above.

2. According to the authors, a multidisciplinary approach of the aesthetic dental treatment may synchronize all of the following EXCEPT:a. Periodontics.

b. Orthodontics.c. Endodontics.d. Plastic surgery.

3. Harmony of the whole facial appearance isinfluenced by all of the following conditionsEXCEPT:a. Ethnicity.b. The biologic width.c. Variations in preference.d. Principles of specific symmetries and relations.

4. The optimal position for an evaluation of thefrontal plane is:a. Not important.

b. The natural postural head position.c. The natural head position.d. The natural postural position.

5. Important landmarks for the evaluation of smileharmony include all of the following EXCEPT:a. Sagittal line.b. Facial midline.c. Commissural line.d. Interpupillary line.

6. The low, medium, or high position of thelip line can be observed during:a. A neutral smile.b. A natural smile.c. An inverted smile.d. The position of the lip line cannot be observed

with the human eye.

7. The orientation of the anticipated dentalmidline can be influenced by the:a. Incisal plane.b. Occlusal plane.c. Visible length of the maxillary teeth.d. Dorsum of the nose and its curvature.

8. A complete diagnosis requires the preciseevaluation of which factor?a. The facial contours.b. The cephalometric linear measurements.c. The position of the nose, lips, and chin.d. All of the above.

9. An aesthetic lip configuration in a lateral view is related to:a. The position relative to a line drawn

between the base of the nose and the chin.

b. Tooth support.c. Bone support.d. The throat length and contour.

10. “The symmetry of the face and dentalmidline is defined by the facial midline.”This statement is:a. True.b. False.

872 Vol. 12, No. 9

To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and

complete as follows: 1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3)

Clip answer sheet from the page and mail it to the CE Department at Montage Media Corporation. For further instruc-

tions, please refer to the CE Editorial Section.

The 10 multiple-choice questions for this Continuing Education (CE) exercise are based on the article “Facial analysis:

A comprehensive approach to treatment planning in aesthetic dentistry” by Robert Rifkin, DDS. This article is on Pages

865-871.

Learning Objectives:This article describes a method of quantifying various measurements of the face in order to create a comprehensive dental

plan that satisfies patient aesthetic expectations. Upon reading this article and completing this exercise, the reader should:

• Demonstrate an understanding of the interdisciplinary relationship between all members of the restorative team.

• Be able to construct a comprehensive dental plan based on a patient ’s functional and aesthetic facial

deficiencies.

CONTINUING EDUCATION

(CE) EXERCISE NO. 31C E CONTINUING EDUCATION

31

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